Adolescent Sleep Behavioral Interventions and Opportunities to Improve Cognitive Functioning: A Call for Action

Sleep is related to cognitive functioning, learning, and brain development in the adolescent population. Recent research indicates a rise in the presence of chronic sleep disorders such as insomnia in adolescents, particularly following the COVID-19 pandemic. Therefore, research on the effectiveness of sleep interventions for adolescents is necessary to guide treatment in adolescents. The authors conducted a systematic review of literature examining research on outcomes of treatment interventions for insomnia on sleep quality and cognitive functioning in adolescents. Results indicate a dearth of research examining effectiveness of treatment in adolescents, particularly in relation to the impact of such treatment on cognitive functioning in adolescents. The following paper provides a brief overview of existing research on treatment of insomnia or related problems including initiating, maintaining and awaking for adolescent populations with a focus on improvement of cognitive functioning within this population. The authors discuss existing barriers to research, emphasize the need to expand sleep research to include cognitive functioning outcomes, and inform best practices for treatment in adolescents following COVID-19. Lastly, the authors propose a call to action encouraging more widespread recognition of the need for research in this area. Key Take Away Points 24 out of 735 records identified through databases were screened for eligibility. The search and subsequent screening procedures outlined several limitations including a dearth of randomized clinical trials, RCTs assessing effectiveness of behavioral interventions specific to insomnia, adequate selection of cognitive functioning measures, sleep assessment measures and other study designs limitations. Only two records remained in the study with CBTi interventions and included objective measures specific for the assessment of insomnia and cognitive functioning. The two remaining studies reported changes in their interventions for working memory tasks;however, effect size and other study design limitations were reported. Barriers and considerations for the insomnia related symptoms and treatment continues to merit attention due to its impact for learning in adolescent population.

Real-World Evaluation of Clinical Response and Long-Term Healthcare Resource Utilization Patterns Following Treatment with a Digital Therapeutic for Chronic Insomnia.

Background and Objectives: This analysis evaluated insomnia severity and long-term impact on healthcare resource utilization (HCRU) and costs after treatment with Somryst® (previously called SHUTi), a digital therapeutic delivering cognitive behavioral therapy for insomnia (CBT-I). Methods: Change from baseline in insomnia severity index (ISI) score was assessed using last observed ISI score. A pre/post analysis of claims data was conducted, comparing HCRU in patients with self-identified sleep problems who successfully initiated the therapeutic (index date) between June 1, 2016 and December 31, 2018. Results: A total of 248 patients were analyzed (median age 56.5 years, 57.3% female, mean ISI score 19.13, 52.4% treated with sleep aid medications pre-index). After 9 weeks, mean ISI score declined by 37.2% from baseline (19.1 vs 12.0), 58.8% of patients achieved ISI responder status (ISI score improved by =>7; NNT: 1.7), and 26.6% of patients achieved insomnia remission (ISI score <8; NNT for remission: 3.8). After two-year follow-up, post-index events were reduced (compared to 2 years pre-index) for emergency department visits (-53%; IRR: 0.47; 95% CI 0.27, 0.82; P=0.008), hospiatizations (-21%; IRR: 0.79; 95% CI 0.46, 1.35; P=0.389) and hospital outpatient visits (-13%; IRR: 0.87; 95% CI 0.66, 1.14; P=0.315). Slightly increased rates were observed for ambulatory surgical center visits (2%; IRR: 1.02; 95% CI 0.73, 1.44; P=0.903) and office visits (2%; IRR: 1.02; 95% CI 0.92, 1.14; P=0.672). The number of patients treated with sleep aid medications dropped 18.5% (52.4% pre-index vs 42.7% post-index). Average number of prescriptions decreased from 3.98 pre-index to 3.73 post-index (P= 0.552). Total two-year cost reduction post-index vs pre-index was $510,678, or -$2059 per patient. Conclusion: In a real-world cohort of patients with chronic insomnia, treatment with a digital therapeutic delivering CBT-I was associated with reductions in insomnia severity, emergency department visits, and net costs.

Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All?

Purpose: Insomnia is a highly prevalent disorder that is seen across all age groups causing significant morbidity to the patients. Its prevalence has further risen during COVID-19 pandemic. It is widely acknowledged that untreated insomnia can lead to significant health risks and socio-occupational dysfunction. Methods: A narrative review was conducted following focused search of databases. Results: Available guidelines mention two different approaches for the management of insomnia-pharmacological and non-pharmacological. Non-pharmacological therapies like multicomponent cognitive behavior therapy for insomnia (CBT-I) have been advocated for the management of acute as well as chronic insomnia in the literature as it has been found efficacious and useful. Multiple variants of CBT-I, e.g., digitally delivered CBT-I, brief CBT-I have been tested during pandemic owing to closure of clinics. However, there are certain issues to be considered while choosing CBT-I as therapy. For example, like other forms of psychotherapies, is there a need for assessing the candidature of patient before administering CBT-I; is CBT-I free of adverse effects as commonly thought; is CBT-I more efficacious than hypnotics; and at last, how to manage cases that are not candidate for CBT-I. Conclusion: This narrative review addresses the scientific robustness of evidence for issues related to adherence, efficacy and adverse effects of non-pharmacological therapies. Available literature suggests that data related to adherence and efficacy of CBT-I suffer from methodological shortcomings and careful selection of patient is important for the successful therapy. At the same time, attempts have been made to shed light to the areas where CBT-I can be helpful in the management of insomnia.

Mental status of patients with chronic insomnia in China during COVID-19 epidemic.

AIM: To study the sleep and mental health of chronic insomnia patients in China during coronavirus disease in 2019 (COVID-19) epidemic. METHODS: A total of 764 patients with chronic insomnia were included in this study. From 17 January 2020 to 24 January 2020, insomnia, anxiety and physical symptoms were evaluated online, and they were followed up for 4 and 8 weeks. Main outcomes and indicators were assessed using the Pittsburgh Sleep Quality Index (PSQI) and each factor score, the General Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-15 (PHQ-15), respectively. In addition, insomnia, anxiety and physical symptoms were assessed at baseline and at the end of fourth and eighth weeks. Wilcoxon signed rank test was used to compare the changes in patients' scale scores at different time points. RESULTS: Among the 764 participants, there were 755 and 738 evaluators who completed the fourth and eighth weeks, respectively, and the questionnaire completion rates were 98.82% and 96.60%, respectively. Among them, there are 459 (60.0%) aged 41-60 years old, 546 (71.5%) women, 218 (28.5%) men and 313 (41%) college degrees. After 8 weeks of follow-up, the differences in sleep status, anxiety symptoms and physical symptoms were statistically significant. Among the factors of PSQI, there were differences in subjective sleep quality, sleep latency, sleep duration, sleep disturbance (disorder), sleep efficiency and daytime function. At 4 weeks of follow-up, there was a statistically significant difference in the use of hypnotic drugs; at 8 weeks of follow-up, there was no statistically significant difference in the use of hypnotic drugs. CONCLUSION: Under the influence of the COVID-19, the sleep status and anxiety of patients with chronic insomnia are affected by the epidemic.

Efficacy of simplified-cognitive behavioral therapy for insomnia(S-CBTI) among female COVID-19 patients with insomnia symptom in Wuhan mobile cabin hospital.

BACKGROUND: The outbreak of Coronavirus Disease-2019 (COVID-19) caused great psychological distress often with comorbid insomnia. Insomnia is common in patients with COVID-19 admitted to mobile cabin hospitals. Insomnia may lead to immune dysfunction, a condition not conducive to recovery from COVID-19. The use of sedative-hypnotic drugs is limited by their inhibitory effect on the respiratory system. A paucity of research is available regarding psychotherapy interventions to improve insomnia symptoms among  patients with COVID-19. In the general population, sleep problems are more common in women than in men; insomnia in women patients requires special attention. The aim of this study was to develop simplified-cognitive behavioral therapy for insomnia (S-CBTI) for patients with COVID-19 and comorbid insomnia symptoms and to verify its effectiveness through a self-control trial. A second aim was to compare the effectiveness of S-CBTI between acute and chronic insomnia among women with COVID-19 and comorbid insomnia symptoms in Wuhan Jianghan Cabin Hospital. METHODS: S-CBTI consisted of education on COVID-19 and sleep hygiene, stimulus control, sleep restriction, and self-suggestion relaxation training over a period of two consecutive weeks. Of 67 women, 66 completed psychological intervention and baseline and post-intervention assessments. There were 31 women with acute insomnia and 35 with chronic insomnia. The Insomnia Severity Index (ISI) score and self-compiled sleep data were assessed at baseline and post-intervention, and subjective sleep evaluations were assessed at days 4, 7, 12, and 14. RESULTS: The ISI score, sleep latency, night sleep time, and sleep efficiency were statistically significantlly improved from baseline to post-intervention by paired T-test. After the intervention, the mean ISI score of the acute insomnia group was lower than that of the chronic insomnia group. The reduction of the ISI score and the improvement of sleep time from baseline to post-intervention in the acute insomnia group were greater than those in the chronic insomnia group. Utilization of sedative-hypnotic drugs in the acute insomnia group was less than that in the chronic insomnia group, and the difference was statistically significant. CONCLUSIONS: S-CBTI can improve the insomnia symptoms of women with COVID-19 in mobile cabin hospitals, especially for stress-related acute insomnia.

Profile of Somryst Prescription Digital Therapeutic for Chronic Insomnia: Overview of Safety and Efficacy.

Introduction: Prescription digital therapeutics (PDTs) represent a new class of software-based medical devices authorized by the Food and Drug Administration (FDA) to treat disease. Somryst™, the first PDT for treating chronic insomnia, delivers cognitive behavioral therapy for insomnia (CBT-I) via a mobile application. CBT-I is the guideline-recommended, first-line treatment for chronic insomnia, but availability of CBT-I therapists is limited. Somryst addresses this need by providing asynchronous access to CBT-I treatment. As a contactless therapeutic medium, Somryst is also an ideal option when face-to-face therapy is not available or recommended for safety reasons (e.g. because of possible exposure to the SARS-CoV-2 virus). Areas covered: This review summarizes the mechanisms of action and technical features of Somryst, and describes safety and effectiveness data from the randomized trials on which FDA clearance was based. Expert opinion: Somryst demonstrates robust clinical efficacy with a favorable benefit-to-risk profile for treating adults with chronic insomnia. FDA clearance was based on data from 2 clinical trials of the first-generation web-based CBT-I platform Sleep Healthy Using the Internet (SHUTi). Somryst, and PDTs in general, are promising devices to address the need for greater accessibility to effective therapies.